African-American women are 25 times more likely than white women and four times more likely than Latina women to have an AIDS diagnosis.

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16- to 21-year-old African-American women are seven times more likely than white women and eight times more likely than Latina women of the same age to be HIV positive.

In 2001, HIV/AIDS was the number one cause of death for African-American women aged 25-34 and among the top four causes of death for African American women ages 20-54.

From "HIV/AIDS Among Women" Centers for Disease Control and Prevention.

In the U.S., HIV infection rates are rising fastest in women. Globally, women now account for half of people living with HIV. In the U.S., where 25% of all women are African-American or Latina, they account for 83% of all new HIV cases, with most of these infections occurring in African-American women. Other populations traditionally considered "at-risk," such as men who have sex with men (MSM) and IV drug users, have seen HIV infection rates drop in the 25 years since the epidemic began. Now, heterosexual African-American women have also become a significant risk group. Having a history of sexual abuse, poverty, violence, or limited educational and economic opportunities can also increase the risk.

Why is this happening? How does a woman's environment, culture, socioeconomic status, education, race or age affect her ability to express herself sexually and to negotiate safer sex? Do biological factors increase a woman's chance of infection? Are HIV prevention campaigns failing to provide prevention education that utilizes gender-sensitive and rights-based approaches? Is it due to a lack of female-controlled prevention methods? Are other factors at play, such as sexual and domestic violence?

Clearly, there are many issues contributing to these increasing infection rates. Socially defined gender roles and stereotypes limit a woman's social and economic power and her right to healthy relationships. Any discussion of HIV in the U.S. must consider the role that gender plays in women's lives and sexuality.

Dynamics of Women's Sexual Practices

The overwhelming HIV risk factor for women today is heterosexual sex, which accounts for 79% of HIV infections in women in the U.S. Has this changed women's sexual practices and relationships? To find an answer, one must examine a variety of racial, cultural and social factors. In a study on relationship dynamics, ethnicity and condom use among low-income women conducted by The Center for the Study of Population at Florida State University, African-American and Latina women reported higher levels of consistent condom use than white women. In the same study, women who made monetary decisions independently were more likely to be consistent condom users than women who didn't participate in financial decisions. Even women who shared in financial decisions were less likely to use condoms than women who were financially independent. These findings suggest that race and culture alone aren't the determining factors for African-American and Latina women's disproportionate HIV infection rates. Socioeconomic independence may be more important.

In a large study of 56,000 adult men and women, only half of women question potential partners about STDs, with African-American women more likely to have such conversations than white or Latina women. Unfortunately, such questioning can lead to a false sense of security and lower rates of condom use. The study also found that 66% of study participants have had unprotected sex while under the influence of alcohol. Alcohol and drugs were the biggest risk factors for unprotected sex among both men and women in every demographic subgroup.

We interviewed ten young African-American single women for this issue, asking them the question: "Has HIV changed the sexual practices of your peers?" The answer was a resounding, "No!" While one of the ten women interviewed had moved away from penetrative sex (even using condoms during foreplay), the others stated that none of their sexual activities had changed. One young woman claimed that her peers were using dental dams for oral sex (though she did not); the older women had never used them. There was clearly more concern about condom use during anal sex as opposed to vaginal sex. The one activity that had changed was group sex; those who had been engaging in it were less likely to do so after seeing the rise in numbers in infection rates for African-American women. All ten women knew they were HIV negative, but not if their partners were. Only two of the women knew about the window period (the three-month period between HIV infection and a positive HIV antibody test), and most were misinformed about basic HIV information they thought they knew.

The "Down Low"

One recent topic of much discussion has been men who have sex with men outside of their relationships with women, known in certain circles as being "on the down low." There are those who attribute the high infection rates in African-American women largely to "down low" activities, to the extent that there are now guides on how to know if your partner is "on the down low." A recent Chicago study of 5,000 HIV-positive MSM found that African-American men reported high rates of sex with women, regardless of whether they identified as gay, bisexual or straight. And a recent review article in the Journal of the National Medical Association concluded that "non-gay-identified men of other races...also engage in in homosexual sex and do not disclose their homosexual behavior to female partners, [but] the high background prevalence of HIV and the greater odds of bisexual activity among black men" make this a "pressing issue." So, although this behavior is not limited to the black community, African-Americans have been the hardest hit by this activity.

Other studies have found that, even when many African-American women are aware of their partners' sexual practices with other men, they still engage in unprotected sex. What are the reasons that African-American women would knowingly put themselves at increased risk for HIV infection? One of the findings supported by this research says the lack of African-American male partners influences black women's sexual choices. The study supports the proposition that bisexual activity among African-American men places heterosexual African-American women at risk for HIV infection.

Assumed Monogamy

Women who are married or in what they presume to be monogamous relationships are not exempt from HIV infection. Worldwide, over 80% of new infections in women occur among those who are married or in long-term relationships. In low-income areas of New York City, women are more than twice as likely to be infected by husbands or steady boyfriends than by casual sex partners.

Often a woman doesn't learn her partner's status until after his death, leaving her with grief combined with resentment and feelings of betrayal, especially upon discovering that their partner knew his status and never revealed it while continuing their sexual relationship. Many married women think their marital status keeps them safe from HIV infection. Single women, especially those with one partner, put themselves at risk by assuming their partner is being faithful while having unprotected sex. Women often believe that as long as their partners aren't bisexual or IV drug users, they are safe, yet it is clear that assuming one is in a monogamous relationship can be high-risk.

Women Who Have Sex With Women

When talking about the dynamics of women's sexual practices we must include women who have sex with women (WSW), although data on HIV and WSW is very limited. Female-to-female transmission is far less likely than male-to-female transmission. The most current data from the CDC show that through December 1998, 2% of women with AIDS reported having sex with women. These 2,200 women also reported other risk factors, like IV drug use and sex with high-risk men. 347 women reported having sex only with women, but they also reported other risk factors, IV drug use being the main one.

The perception that women cannot infect other women with HIV can actually put WSW at risk. Although data are limited, it appears that in the few cases where female-to-female sexual transmission has been thought to occur, contributing factors like sharing sex toys, the presence of blood during sex, and former heterosexual sex by at least one female partner was reported. Yes, the HIV infection rate among this group is low, but it cannot be discounted. More data that adequately represent all women are needed so that women can have access to the information needed to protect themselves.

Young Women

One out of four AIDS cases in women are among young women aged 29 or younger. This is a higher proportion overall than for young men (one out of six). Young women today have known sexual experiences only in the era of HIV/AIDS, and the majority of HIV-positive women ages 13-24 were infected through sexual relationships with HIV-positive men. Has growing up knowing about HIV shaped the way young women make sexual choices?

Surprisingly, it seems that knowing about HIV has little or no influence over young women's sexual behavior. Rather, most sexual protection decisions seem to be based on pregnancy prevention. A 1999 New York study of African-American and Latina adolescents found that condom use among women who used some type of hormonal contraception was low. Instead, adolescent girls who used either oral contraceptives or long-acting agents such as Depo-Provera were less likely to use condoms than other sexually active teen girls. In another study, African-American female adolescents reported that not using a condom was a sign of intimacy and trust.

Yet, due to a variety of factors, young women are at increased risk for contracting HIV and other STDs. Biologically, young women are more physically vulnerable to contracting HIV during sex. Additionally, sexually active young women often have male partners who are older, and as the age difference increases, so does the probability that sex is unprotected. Young women often have inaccurate beliefs about protecting themselves from HIV infection. Many believe that being in a sexually exclusive relationship is adequate protection, even if they live in an area with high HIV infection rates.

Knowing how to prevent HIV infection may not always be enough to protect young women. Rather, it seems that often they feel they do not have the right to make sexual decisions. A Texas study of 904 sexually active young women between the ages of 14 and 26 found that almost 20% believed they never have the right to refuse sex, ask their partner his STD status, or say if their partner is being too rough. Clearly, sexual coercion and adherence to harmful gender roles is a reality for many young women who do not feel they have the power to choose when and how to have sex. Young women who have suffered sexual abuse or coercion are also more likely to have earlier sexual experiences with multiple partners, putting them in at higher risk for contracting HIV and other STDs.

In the context of HIV prevention education for young people, programs that solely teach abstinence until marriage are an unfortunate reality. While education about abstinence is important, "abstinence only" programs that censor information about contraception disempower young women. Numerous studies have shown that sex education that includes information on both abstinence and contraception is the only effective way to lower teen pregnancy and STDs. The current administration's doubling of funding for "abstinence only" education, is increasing young women's vulnerability to HIV. Funding priorities should be given to comprehensive sexual education programs that have proven effective at delaying the onset of sexual activity, reducing the frequency of sexual activity, reducing the number of sexual partners, and increasing condom and contraceptive use among young people.

Sexual Violence

The links between gender-based violence and HIV infection are undeniable. The physical, sexual, and psychological abuse of women and girls crosses all cultural and socioeconomic boundaries and is usually perpetrated by family or intimate partners. Gender-based violence is the most common form of violence that women face, yet it is estimated that more than 50% of sexual assaults go unreported. Still, based on reported numbers, in the U.S., one in six women is a survivor of rape or attempted rape and girls ages 16 to 19 are four times more likely than the general population to be sexually assaulted.

A 2002 UCLA and Drew University study of 490 women in Los Angeles found that a history of childhood sexual abuse was a primary risk factor for HIV infection. Other studies have shown that survivors of physical and sexual abuse were more likely to be abused in the future as well. Women who had suffered chronic childhood sexual abuse or had been raped as adults were not only much more likely to engage in unprotected sex as adults but were more likely to be in abusive relationships. A World Health Organization study on domestic violence also found that women in physically or sexually abusive relationships have an increased risk of contracting HIV. These women also reported more frequently than others that their partners had multiple sex partners and refused to wear condoms.

Fear of violence plays a large role in the way women access and act on information related to HIV, limiting their ability to negotiate condom use during sex. Women who fear or suffer domestic violence are less likely than others to suggest condom use, seek out HIV/AIDS information, be tested, disclose their HIV status, or obtain services for the prevention of mother-to-child HIV transmission during pregnancy.

Prevention

The HIV epidemic has different implications for women than for men. During heterosexual intercourse, women are more vulnerable to HIV and other STDs than their partners, due to larger mucous membranes that are exposed during sex, greater transfer of fluids from men to women, and microscopic tears to the vagina that occur during intercourse. In addition, untreated STDs, which are more frequent in women, increase the chance of HIV infection.

Current HIV/AIDS prevention options are limited, and none are woman-controlled. Often, women lack the social or economic power to demand the use of condoms. The female condom is currently the only form of protection that is woman-initiated. Yet, since the female condom is a visible barrier, male consent is necessary for it to be used. Therefore, while providing an alternate form of protection, it is not protection that a woman solely controls.

Microbicides are the only prevention method that could be applied without a partner's knowledge. A range of microbicides are in development (see article on page 18) that would provide protection from HIV and other STDs, and in some cases pregnancy. In the form of gels, foams, creams, suppositories, films, rings, or sponges applied vaginally and in some cases anally, microbicide use will be dictated solely by the person applying it. Unfortunately, development has been slow and approval remains years away, highlighting the fact that research on woman-controlled prevention methods is often not a high priority and resources for it are scant.

Since microbicide development may not be in the economic self-interest of pharmaceutical companies, funding must come from the public sector, and unfortunately has not been rapidly forthcoming. In addition, many HIV/AIDS advocates worry that, once approved, high prices will make microbicides unaffordable for poor women. This is especially a concern for women in developing countries -- the very countries most in need of such life-saving technologies. Once proven safe and effective, microbicides must be accessible and affordable for all if they are to have a significant impact on reducing HIV infection rates.

Final Thoughts

There are so many issues surrounding the HIV/AIDS epidemic and the ways it pertains to women's sexuality. For this article, we focused primarily on the complexity of the issues women today face in order to have intimate and sexual relationships in the context of HIV/AIDS.

Through our research we found that even words used to describe women's sexual behaviors, such as "negotiating," seem better reflective of a business transaction than of what for many women is an intimate and emotional experience. Yet the actions we must take to protect ourselves in our sex lives often mirror just that.

Unfortunately, we found that women seem to not be "negotiating" sexual protection effectively. Many of the reasons for this have to do with prevailing societal norms that perpetuate the idea that women do not have the right to control their bodies and sexual encounters. Gender roles and stereotypes such as these lead to unequal power dynamics in relationships and economic dependence. Other factors such as violence against women and lack of education, female-controlled prevention technology, and adequate research and funding on women only serve to exacerbate an unequal status quo that puts women at risk.

Yet, our findings also showed that women engage in dangerous risk-taking in the name of emotional and physical connections. It seems we often equate intimacy and trust with not verifying a potential partner's HIV and STD status before having sex, trusting in supposed fidelity, and engaging in condomless sex. And young women are learning this from us. Our need for sexual and emotional connection must not outweigh our better judgments to protect ourselves.

Clearly, the more empowered we are in our relationships, the better able we are to protect ourselves, not only from HIV infection but from other harm as well. So, what makes women feel powerful? The lack of research on women on this subject unfortunately leaves us no alternative but to rely on smaller studies and to look into our own lives for answers. These are: having goals for ourselves, knowing what we want, and having the ability to achieve it; intrinsically valuing what we have to offer; having the resources to provide for our families; and feeling physically attractive and sexually independent. When we buy into societal norms and expectations that limit our abilities to make informed choices we are limiting our power in our sexual lives.

To be successful, HIV initiatives must address obstacles to women's healthy sexual behaviors. Public policy initiatives should prioritize programs that enable women to overcome these obstacles and fund adequate research on women. Finally, only when we are truly honest with ourselves about issues and situations that are harmful to us and finding ways to deal with them will we really see infection rates in women drop.

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